GW1-2021-02289_Well Construction - GW1_20210521

WELL CONSTRUCTION RECORD(GW-1) Forintemal Use Bitty:
1.Well Contractor Information:
Alfred Kiesling Sr +a 1411:Ai TtZO1V S:.;:;:;:::.::.«::::::::: .:::;:::: .;::::: ... . ... .
FROM TO DECRYPTION
21 Well Contractor Name 1 Z021 �, ft. !; ft. j n� 1-
2670-A I��A`( ��tt 7©�ft r #kU
NC Well CorinactorCertificationNumber
r; �f^wr�J;)1T1�1}i�li
�S t��il;�3'`•C^i1 1 cr^'Ol'1 FROM
f�rm'ditri�zseti�"tc�1s E112 THICKNESS fMA ERLaL
B & K Well Drilling Inc ata� ���� TO
p ft. j D (t 6 1/4 to ISDR-21 PVC
Company Name _.. .
� ��]1 � f�
2.Well Construction Permit#:L..J t--•—� {��J-2"I I FROM To utaMIFFER t tttCi<nts5 MATERIAL
Lis,all applicable well co,. reion pe mili e-VIC,Corvay.State.Var: wc,arc.} It. ft. in-
tt.
3.Well Use(cheek well use): to
Water Supply Well: FROM
TO DIAMETER SLOT SIZE THICKNESS MATERIAL
OAgricultural DMunicipal/Public ft, t'L in.
OGeothennal(HeatingiCooling Supply) 6esidential Water Supply(single) Et. ft in.
e 'Olnd u str tat Co n uu vela! OResidential Water Supply(shared)
Dlrrioation OWells>100,OOOGPD FRUIII TO I MATERIAL EMPLACLMIVT METHOD&AMOUNT
Nun-Water Supply Well: 0 ft- 20 ft' 136ntoni e Pour
Oihonitoring ORccoccry It. ft.
Injection Well:
III. ft.
DAquifer Recharge D<iroundwater Remediation
�sLK..S.�iY�'!Gitt4L"�a,:P?YL#�trsf ''hcsblel -S'•....,. :'.r::ss:.
OAquifer Storage and Recovery OSahnity Barrier FRunt To I NIATF.RIAL FMPIACEMF.NT METHOO
OAquifer Test OStormw'ater Drainaee ft, R.
DExperimentai Technology OSubsidence Control ft. fit.
❑Geothermal(Closed Loop) OTracerFP.Q" :1 [31 iU 'attxeti tzunaEs�te+#a3�necesar l r .':::'::.:.':;
OGeothennal(HeatinJCoolin Return) DOther(explain under#21 Remarks) M To DESCRIPTION oobr.hardn ivrock e- to Sze etc.)
S k ) ft. �ft. 14 � I
�1 p� �
4.Date Well �.
s)Completed: =`-J Well ID# X V WA" t-p t tf
V ft. 1
Sa.Well Lor• on: VI
CC ft.
In5n,6 allM.t-„s
FacilitylOwner Name ,r r Facility il)+t ifapplicable) ft- ft.
I Y i d�tom, � -`e' ft. ft.
Physical Address,City.and Zip � ft. ft.
County Ptuccl Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if wcll field,one lat:lona is sufficient) 2Z.Certification-
N W �"z
6.Is(are)the well(s): 17Permanent or ❑Temporary -signail,of Certified Well Contractor Date
Br si r iagg this tarn.I herelr r ertijir that the r11(sJ uas(were)<onsirurled in arvordanre with
7.Is this a repair to an existing well: O Yes or InNo 15A NCAC Ok.0100 ar 15.1.'rCAC 02C.0200 Well Construction Standards and that a copy
q'rhis is a repair.fl/our known well rnnetnrcrtinn inrnrinaiinn and explain the nolure of the ofthit record has beenprortded to the nrl/owner.
repair tnrder ti21 remarks sec.tion or an the back ofthic form. -
23.Site diagram or additional well details:
S.For Gtmprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional fages if necessary.
drilled:- _� 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: �d'5 (ft) Submit this GW-t within 30 days of well completion per the following:
For nnrtripte netts list all depiht if eft fer'ent(Trample-3(aLW0 anel2@1001
24a. For 411 Wells: Orisinal form to Division of Water Resources (DWR),
10.Static water level below top of casing:�� (ft.) information lirocessing Unit,1617 MSC.Raleigh.NC 27699-1617
Ij\ruler level is abate cnsing.use"+"'
tl.Borehole diameter 1/$ f •) 24b,For Injection Wells:Copy to DWR,Underground Injection Control(iUC)
Program,1636 MSC,Raleigh,NC 27699-1636
uction method:
Air Rotary4c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
12.Well rnnsrr 2
(i.e.auger.rotary.cable.direct push.etc.) county environmemal health department of the county whereanztalled
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100.000 GPD:Copy to DWR.CCPCUA
1� Air Lift PertnitPro_ram,1611 MSC,Raleigh.NC 27699-1611
13a-Yield(gpttt) /l/ Method of test:
136-Disinfection type: Chlor. Tabs Amount: 1 1/2 Lbs
i
Form G W-1 North Carolina Depantncnt of Em iroamental Quality-Division of Water Resources Revised 6-6.201 R